ATP Conference Feb 2013

I am happy to report that the ATP conference was great, and as usual the highlight was catching up with old friends. I must apologize I didn’t remember to take a picture of the group, and I’ll offer the excuse that we’ll just have to wait until next year when more of our group can join.

I submit to you my list of “what I’ve learned” at the ATP conference this year 2013.

1. Medicine is changing, and quickly, much faster than in the previous decades it seems to most of us. I don’t think you need me to elaborate on this, I think you’re all living it, whether as doctors, hospital administrators, or people who have health insurance and occasionally see a doctor or know someone who needs/has insurance and wants to see a doctor.

2. No one has the answer yet. People are doing all kinds of great work and it seems that more people have figured out how to improve processes (e.g. joint replacements, which along w/ cardiology and OB/GYN seem to be where the money lies), but a look at the whole is still beyond reach. I still think to David Eddy’s talk last year (he didn’t come this year) where he pointed out that every society comes out with a guideline and recommends that we adhere to it (however lacking the evidence), but no society tells you to ignore their guideline and focus on a more important guideline. If only we had a “global outcome” (his GO score is an attempt at that) where you could intervene on big things to get overall improvement even if you choose to ignore other “quality measures” or “guidelines” that don’t seem as important to focus on. The principle sounds nice, but in this transition environment no one has figured out how to do this yet that I could tell. In Boston big hospitals are buying community hospitals and setting up chains, so that you can do your $10K hip replacements in the community hospital and not the $15K hip replacement at the University hospital. Interestingly, there’s a for profit new chain of hospitals in Boston.

3. Process improvement does not necessarily result in happiness. By now we’re no stranger to the pilot talk about changing pilot culture. We had one of those and the speaker was perfectly nice and made the same points we’ve heard before. But one of the audience members asked if after all these improvements pilots are happier. Because, as he said, he is trying to sell these improvements to his colleagues as things that will make their lives better, make care better. And my understanding of the pilot’s answer was a clear “NO.” They are not happier. Flying is safer, but contract negotiations with management are apparently a great morale boost for pilots, and generally the prestige and morale of the profession has plummeted.

4. No matter the strides we make, we still go back to bad apples. The recent episode of pilots who were so distracted with something while flying the plane and flew over their destination (Minneapolis) for several hours comes to mind. Even after all these years of enlightened root cause analysis and communication improvement, this problem was solved by getting rid of the bad apples. It’s usually easier to explain something away than to find the root cause.

5. System errors do not come in isolation. This insight was courtesy of the keynote speaker on the last day, which I regret I had to miss. But he pointed out that in doing root cause analysis you can find a person, then a system, then the person who designed the system, then a system, then a person and on and on. He said he tries to focus on the system rather than the person because that is most useful in changing things for the organization. However, this is a separate process than the management and employee relations etc. that can deal with the person.

6. Malpractice and Schwartz Rounds – this is courtesy of Ash. The malpractice experiment in Michigan where there is disclosure and fair compensation outside the malpractice suit system and has resulted in reduced fees with more reasonable/fair payment to people actually injured is gaining traction. Ash has great examples of how it’s working at Milton. Schwartz rounds are ways of discussing difficulty in taking care of patients, thinking about the emotional toll of medicine.

7. I’m still struggling with what the role of doctors is and how we can make the biggest difference. On the one hand if you look at the greatest improvement, it’s clear that what’s needed is public health. If you can fix obesity, tobacco use, inactivity you’re likely to have far more improvement than treating the diabetes, COPD or CAD. On the other hand, what we’re doing with the process improvement and what I see as current QI is the equivalent of “putting out guidelines” for our patients and telling them that they’re important to follow. They see a pulmonologist who is very concerned about a 6mm incidental pulmonary nodule and urges them to make sure to get follow up, they see their PCP who counsels them to stop eating junk food and lose weight while quitting smoking, they see a cardiologist who wants to image their coronary arteries and give them a calcium score only to then tell them to take aspirin and a statin that gives them muscle aches, all the while they have lost their job, are about to lose their insurance and can’t afford any of the tests or the medications. It seems that what people would want from their doctor, perhaps the PCP, is someone to put this in context and tell them to forget the dieting and focus on tobacco cessation or counseling or whatever. Someone who can align what the patient sees as important with what the clinicians see as important. But, and here’s the rub, when we actually aspire to do this, we are so very terrible at it! Name a quality measure and we fail it spectacularly when it’s left to the PCP or treating clinician to think through systematically and put every post-MI patient on an aspirin. The main way we are able to improve on these QI measures, it seems, is to take a myopic view of that one problem and farm it out to someone else. (Discharge electronic alerts, nodule clinics of various flavors, troponin alerts, etc.)

8. Oh and lest we forget that every small good counts, someone floated the idea that all funding for research should stop until we’ve successfully implemented the care we currently know is needed. I find this akin to arguing that all funding for art should stop until we have fed everyone, or that all funding for healthcare should stop until we have fed everyone.